National Preparedness Month — September 2013

In 2003, recognizing the increasing frequency and complexity of disease outbreaks and disasters and a greater risk for terrorism, CDC established the Emergency Operations Center (EOC), bringing together CDC staff members who respond to public health emergencies to enhance communication and coordination. To complement the physical EOC environment, CDC implemented the Incident Management System (IMS), a staffing structure and set of standard operational protocols and services to support and monitor CDC program-led responses to complex public health emergencies. The EOC and IMS are key components of CDC's Emergency Management Program (EMP), which applies emergency management principles to public health practice. To enumerate activities conducted by the EMP during 2003-2012, CDC analyzed data from daily reports and activity logs. The results of this analysis determined that, during 2003-2012, the EMP fully activated the EOC and IMS on 55 occasions to support responses to infectious disease outbreaks, natural disasters, national security events (e.g., conventions, presidential addresses, and international summits), mass gatherings (e.g., large sports and social events), and man-made disasters. On 109 other occasions, the EMP was used to support emergency responses that did not require full EOC activation, and the EMP also conducted 30 exercises and drills. This report provides an overview of those 194 EMP activities.

The EMP can access all of CDC's organizational resources, enabling synchronization of public health emergency response activities and communications with international, federal, and state partners.EMP public health response activities are categorized as activations, utilizations, exercises and drills (Figure 1), and public health triage.Activations must be approved by the CDC Director and include use of the IMS, which includes the gathering of key staff members from across CDC to the EOC, coordination of planning and communications, logistics support, and field deployments (e.g., to a hurricanedamaged country) for a comprehensive agency-wide response.Utilization does not always require full EOC activation, but employs EMP services to meet the needs of the situation, such as call center operations, development of plans and situational awareness products, and travel assistance.Exercises and drills include full-scale emergency response exercises (deployment of staff and materiel to support a scenario that mimics a real emergency), tabletop exercises (discussion of a scenario), and drills (tests of a single response function).At all times, public health triage is used with telephone call and e-mail requests, linking CDC subject matter experts and resources with key partners, such as state and local health departments, other federal agencies, and public health practitioners.
During activations and exercises, IMS staff structures and protocols are used to support a standardized but flexible approach to CDC's public health response.Use of the IMS response model allows CDC to stay consistent with the incident command structure used by other agencies (4).The CDC center, institute, or office with primary responsibility for the public health problem being addressed (e.g., infectious disease or natural disaster) leads the response using the support structure and resources coordinated by the EMP.
During 2003-2012, CDC supported 55 activations, with an average activation period of 52.9 days (1-394 days [excluding the ongoing polio activation]).The most common type of activation was for infectious disease outbreaks (22,40.0%),including seven (31.8%) associated with respiratory illness.Natural disasters accounted for 16 (29.0%) of the activations, most commonly hurricanes (11, 68.8%).In addition, the EOC and IMS were activated to support the response to nine man-made disasters, seven national security events, and one mass gathering (Table ).The longest activation to date has been the ongoing support of the international polio eradication campaign (643 days as of September 6, 2013).
Forty-one (74.6%) of the 55 activations were for responses occurring within the United States (Table ).During this period, the activations for infectious disease outbreak responses most often were initiated in December; natural disaster activations occurred most commonly in August (Figure 2).Support functions were used 109 times for public health events not requiring activation (Figure 1).These included support for infectious disease outbreak investigations (52 times, 47.7%), natural disasters (31, 28.4%), monitoring of national security events (17,15.6%)and mass gatherings (nine, 8.3%).The most common utilization events were for foodborne disease outbreaks (25).Among the 109 utilizations, 72 (66.1%) occurred in the United States (Table ).The average duration of all utilizations was 10 days (range: 1-92 days).
The EMP either coordinated or was an integral participant in 30 full-scale or tabletop exercises and drills during this 10-year period.Twelve (40%) of the exercises and drills used terrorism event scenarios to test public health system response capabilities.In addition to these 30 exercises and drills, the EMP provided support for many exercises and drills conducted by its federal, state, and local emergency response partners.
Another important service offered by the EMP is its availability 24 hours a day, 365 days of the year to international and domestic partners for referral of telephone and e-mail requests for technical assistance and public health consultation.During 2004-2012, EOC watch officers triaged an average of 23,303 requests per year (range: 14,812).
The EMP provides technical assistance to multiple countries interested in learning more about EOC operations and use of the IMS.In 2013, the EMP sponsored its first five international emergency management fellows.The EMP also supports the Global Health Security Demonstration Project, an initiative conducted in partnership with the governments of Vietnam and Uganda and the World Health Organization, to build capacity for surveillance and detection and response to epidemics.The project has focused on developing plans to build additional EOCs and emergency response capability and to provide laboratory and information technology infrastructure to support global health security.
Preparing for and protecting against public health threats is a key aspect of CDC's mission, both domestically and around the world.The EMP has been used regularly for response to public health threats, including full activation of the EOC and use of the IMS structure or use of selected EMP support services, over the past 10 years.Simultaneously, the EMP has increased the number of drills and exercises that it supports to aid CDC programs in planning and preparedness activities.In recent  The uniqueness of emergency events and the multiple factors that influence their course make it challenging to measure the effectiveness of the EMP.Measures of performance and cost effectiveness associated with preparedness and response have not been clearly defined.In 2012, to assess and strengthen the emergency response, CDC began working toward agencywide accreditation by the Emergency Management Accreditation Program (EMAP).Participation in EMAP has allowed the EMP to begin to identify metrics to assess performance and the cost effectiveness of response activities.
Continued review of the EMP activations, utilizations, and exercises and drills will help CDC better understand and address the needs of its stakeholders, both domestic and international.Further evaluation of the effectiveness of the EMP and training in the use of the EOC and IMS protocols is needed for continued program improvements.Identifying and addressing the challenges faced by CDC staff members when engaged in EMP activities will improve CDC's ability to respond effectively and further strengthen the nation's health security.Despite advances in water management and sanitation, waterborne disease outbreaks continue to occur in the United States.CDC collects data on waterborne disease outbreaks submitted from all states and territories* through the Waterborne Disease and Outbreak Surveillance System.† During 2009-2010, the most recent years for which finalized data are available, 33 drinking water-associated outbreaks were reported, comprising 1,040 cases of illness, 85 hospitalizations, and nine deaths.Legionella accounted for 58% of outbreaks and 7% of illnesses, and Campylobacter accounted for 12% of outbreaks and 78% of illnesses.The most commonly identified outbreak deficiencies § in drinking water-associated outbreaks were Legionella in plumbing ¶ systems (57.6%), untreated ground water (24.2%), and distribution system deficiencies (12.1%), suggesting that efforts to identify and correct these deficiencies could prevent many outbreaks and illnesses associated with drinking water.In addition to the drinking water outbreaks, 12 outbreaks associated with other nonrecreational water** were reported, comprising 234 cases of illness, 51 hospitalizations, and six deaths.Legionella accounted for 58% of these outbreaks, 42% of illnesses, 96% of hospitalizations, and all deaths.Public health, regulatory, and industry professionals can use this information to target prevention efforts against pathogens, infrastructure problems, and water sources associated with waterborne disease outbreaks.
This report includes drinking water-associated outbreaks and other, nonrecreational waterborne disease outbreaks, in which the first illness occurred in 2009 or 2010.Outbreaks were reported to the Waterborne Disease and Outbreak Surveillance System through the electronic National Outbreak Reporting System † † as of October 3, 2012.Two criteria must be met for an event to be defined as a waterborne disease outbreak: 1) two or more persons must be linked epidemiologically by time, location of water exposure, and illness characteristics; and 2) the epidemiologic evidence must implicate water as the probable source of illness.Data requested for each outbreak include 1) the number of illnesses, hospitalizations, and deaths; 2) the etiologic agent (confirmed or suspected); 3) the implicated water system; 4) deficiencies contributing to the outbreak; and 5) the setting of exposure.
During 2009-2019, public health officials from 17 states reported 33 drinking water outbreaks (Table 1).The outbreaks resulted in 1,040 illnesses, 85 hospitalizations (8.2% of cases), and nine deaths.At least one etiologic agent was identified in all but one drinking water outbreak; Legionella was implicated in 19 outbreaks, 72 illnesses, 58 hospitalizations, and eight deaths, and Campylobacter was implicated in four single-etiology outbreaks involving 812 illnesses, 17 hospitalizations, and no deaths, as well as two multiple-etiology outbreaks resulting in 17 illnesses.The number and etiologies of drinking water outbreaks reported every year since 1971 were considered for comparison (Figure).
The etiologies, water systems, water sources, illnesses, and deficiencies identified for drinking water outbreaks and outbreak-associated cases were ranked in order of frequency (Table 2).Legionella caused the majority of outbreaks (57.6%); whereas non-Legionella bacteria caused the majority of illnesses (81.8%).The majority of outbreaks (75.8%) and outbreakassociated illnesses (79.4%) were linked to community water systems.§ § The majority of outbreaks (51.5%) and most illnesses (97.3%) occurred in systems that used ground water sources.The majority of outbreaks (57.6%) involved acute respiratory illness, whereas most outbreak-associated illnesses were acute gastrointestinal illness (92.6%).By deficiency categories, Legionella spp. in plumbing systems was present in the majority of outbreaks (19 [   Abbreviations: AGI = acute gastrointestinal illness; ARI = acute respiratory illness; Hep = hepatitis; Other = undefined; illnesses, conditions, or symptoms that cannot be categorized as gastrointestinal, respiratory, ear-related, eye-related, skin-related, neurologic, hepatitis, or caused by leptospirosis.* Nonrecreational category includes outbreaks involving water not intended for drinking and water of unknown intent but does not include recreational water exposures, which are reported separately.† The category of illness reported by ≥50% of ill respondents.All legionellosis outbreaks were categorized as ARI.§ Value was set to missing in reports where zero hospitalizations were reported and the number of persons for whom information was available also was zero.¶ Value was set to missing in reports where zero deaths were reported and the number of persons for whom information was available also was zero.** Community and noncommunity water systems are public water systems that have ≥15 service connections or serve an average of ≥25 residents for ≥60 days a year.A community water system serves year-round residents of a community, subdivision, or mobile home park.A noncommunity water system serves an institution, industry, camp, park, hotel, or business and can be nontransient or transient.Nontransient systems serve ≥25 of the same persons for >6 months of the year but not year-round (e.g., factories and schools), whereas transient systems provide water to places in which persons do not remain for long periods of time (e.g., restaurants, highway rest stations, and parks).Individual water systems are small systems not owned or operated by a water utility that have <15 connections or serve <25 persons.† † A cross-connection between potable and nonpotable water sources resulting in backflow was a suspected or confirmed factor in this outbreak.§ § Etiology unidentified: contamination of water with sodium hydroxide suspected based upon incubation period, symptoms, outbreak investigation, and laboratory findings.¶ ¶ The other symptoms reported were chemical esophagitis and burns in mouth.*** Facility had an onsite disinfection system that was not operational at the time of the outbreak.
† † † Setting was a recreational facility with multiple buildings.A private well that was originally used for a residence was reclassified as a community water system as a result of the outbreak investigation.§ § § The facility had an onsite chlorine dioxide system; however, there were indicators that the system was not being monitored properly at the time of the outbreak.¶ ¶ ¶ The facility had an onsite chlorine dioxide system and was being monitored for Legionella.**** Reported contributing factors included a temporary disruption in disinfection and a cross-connection between potable and nonpotable water sources resulting in backflow.† † † † Multiple water sources within the facility were identified as possible exposures in this outbreak.
treatment or plumbing systems were noted.Untreated ground water deficiency (i.e., contamination of ground water at the source) was identified in eight (24.2%)outbreaks, distribution system deficiency alone was identified in four (12.1%) outbreaks, and both deficiencies were identified in one outbreak (3.0%).Together, distribution system and untreated ground water deficiencies accounted for 965 (92.8%) of all outbreak-associated illnesses.All five outbreaks assigned a distribution system deficiency (i.e., distribution system or untreated ground water and distribution system) occurred in systems using ground water or mixed ground and surface water supplies; of these, three occurred in systems supplying unchlorinated ground water.Two of the distribution systemassociated outbreaks (one in an unchlorinated supply) resulted from cross-connections (i.e., direct connections between piped water systems containing potable and nonpotable water).
In addition to the drinking water outbreaks, public health officials from 11 states reported 12 outbreaks associated with other nonrecreational water exposure (Table 1

FIGURE. Number of waterborne disease outbreaks associated with drinking water (N = 851), by year and etiology -United States, 1971-2010
included seven outbreaks of Legionella spp.resulting in 99 illnesses and six deaths.The water sources and settings for these outbreaks included cooling towers at a military facility and a hotel/motel setting, a mist/steam device in an industrial facility, an ornamental fountain in a health-care facility, and unidentified water exposures in long-term care, assisted-living, or rehabilitation facilities.The remaining outbreaks involved Campylobacter (two), Giardia (two), and acute gastrointestinal illness of unknown etiology (one) from ingesting water in various outdoor settings.* Public water systems include community and noncommunity water systems that have ≥15 service connections or serve an average of ≥26 residents for ≥60 days a year.A community water system serves year-round residents of a community, subdivision, or mobile home park.A noncommunity water system serves an institution, industry, camp, park, hotel, or business.† The category of illness reported by ≥50% of ill respondents.All legionellosis outbreaks were categorized as ARI.§ Outbreaks are assigned one or more deficiency classifications.Deficiency names have been shortened to fit.A full description of CDC deficiency classification is available at http://www.cdc.gov/healthywater/surveillance/deficiency-classification.html.¶ Two outbreaks had multiple etiologic agent types.In one outbreak, the etiologies were Camplyobacter sp.(i.e., bacterium) and Giardia intestinalis (i.e., parasite).In a second outbreak, the etiologies were Campylobacter jejuni (i.e., bacterium) and Cryptosporidium sp.(i.e., parasite).** Etiology unidentified: contamination of water with sodium hydroxide suspected based upon incubation period, symptoms, outbreak investigation, and laboratory findings.† † Ten outbreaks (763 cases) were in community water systems that used a ground water source exclusively.Of these, three outbreaks (111 cases) were in systems that were documented as not treating the water with a disinfectant, five outbreaks (645 cases) were in systems that added chlorine as a disinfectant, and two outbreaks (seven cases) had no information on disinfection documented.§ § Includes outbreaks with mixed water sources (i.e., ground water and surface water).Three legionellosis outbreaks were associated with mixed source community water systems.One giardiasis outbreak was associated with a mixed source community water system.¶ ¶ Symptoms for one outbreak caused by suspected chemical ingestion were categorized as AGI and other.The other symptoms reported were chemical esophagitis and burns in mouth.*** Hepatitis symptoms are categorized separately.One outbreak of viral hepatitis was caused by hepatitis A.
† † † Deficiency 5A.Drinking water; contamination of water at points not under the jurisdiction of a water utility or at the point of use: Legionella spp. in water system, drinking water.§ § § Multiple deficiencies were assigned to three Legionella outbreaks.In two outbreaks, which contributed five cases, there was a deficiency in building/home-specific water treatment.In one outbreak, which contributed three cases, there was a treatment deficiency outside of the building/home as well as a deficiency in the plumbing system.¶ ¶ ¶ Deficiency 4. Drinking water; contamination of water at/in the water source, treatment facility, or distribution system: distribution system deficiency, including storage (e.g., cross-connection, backflow, and contamination of water mains during construction or repair).The four outbreaks involving distribution system deficiency included three outbreaks in systems using only ground water sources and one outbreak in a system using both ground and surface water.Two of the three ground water systems disinfected with chlorine, one ground water system and the system using ground and surface water did not disinfect.**** Deficiency 2. Drinking water; contamination of water at/in the water source, treatment facility, or distribution system: untreated ground water.
† † † † Outbreak involved both Deficiency 2 and Deficiency 4. Outbreak occurred in a nontransient, noncommunity water system using a ground water source that was not treated with a disinfectant.§ § § § Deficiency 11C.Drinking water; contamination of water at points not under the jurisdiction of a water utility or at the point of use: contamination at point of use, commercially bottled water.

Editorial Note
Since the early 20th century, water treatment processes and regulations have vastly reduced the transmission of illnesses through public drinking water supplies in the United States (1).The outbreaks reported during this surveillance period highlight several emerging and persisting public health challenges associated with drinking water systems.First, Legionella is the most frequently reported etiology among drinking water and other nonrecreational outbreaks.Fourteen of the 15 deaths reported were caused by Legionella, underscoring the need for improved Legionella control and mitigation methods.Second, the large proportion of outbreaks associated with untreated ground water (e.g., well water) indicates that additional efforts are needed to monitor ground water sources and protect them from contamination and to ensure that adequate, continuous disinfection is used when indicated by the results of monitoring and risk analyses (2).Finally, the large proportion (78%) of illnesses observed in outbreaks involving distribution system deficiencies emphasizes the importance of protecting, maintaining, and improving the public drinking water distribution system infrastructure (3) because these deficiencies can lead to widespread illness.
The total number of drinking water outbreaks reported during 2009-2010 (33) is similar to the number in previous 2-year intervals (e.g., 36 outbreaks during 2007-2008) (4).Although Legionella historically has been the most frequently reported etiology among drinking water outbreaks, during 2009-2010 Legionella comprised over half of reported drinking water outbreaks for the first time.In addition, Legionella also caused the majority of other nonrecreational water outbreaks (seven of 12).Legionella outbreaks are particularly challenging to prevent and control, in part because the organism multiplies in plumbing systems within buildings, which usually fall outside of regulatory oversight (5,6).Two of the 19 reported Legionella outbreaks occurred at health-care facilities where treatment systems to control Legionella growth had been installed, underscoring the limited effectiveness of engineering controls in complex plumbing systems.
In contrast to the emerging issue of Legionella, the problem of untreated ground water deficiencies in public and individual water systems persists.Full implementation of the Ground Water Rule, a federal regulation that aims to provide increased protection against microbial pathogens in public water systems that use ground water sources, might reduce the number of ground water outbreaks in public systems (2).However, this regulation does not address private wells, which the Environmental Protection Agency lacks the authority to regulate, emphasizing the continued need for education and outreach to private well owners to prevent outbreaks (7,8).
Distribution system deficiencies continue to be a major contributor to drinking water outbreaks and outbreak-associated illnesses.Three outbreaks occurred in systems supplying unchlorinated water; if a disinfectant residual had been present, pathogens introduced by the distribution system deficiency might have been inactivated before the water reached consumers.Two outbreaks resulted from cross-connections between potable and nonpotable water pipes.The piecemeal nature of some infrastructure development might contribute to the occurrence of these cross-connections, highlighting the importance of distribution system monitoring and adherence to guidelines for the prevention of backflow of nonpotable water into the potable water supply (5,9).
The findings in this report are subject to at least two limitations.First, detection, investigation, and reporting of outbreaks are incomplete, and the level of surveillance and reporting activity varies across states and localities.Linking illness to drinking water is inherently difficult through outbreak investigation methods (e.g., case-control and cohort studies) because most persons have daily exposure to tap water (10).Environmental investigations provide information on deficiencies that contribute to outbreaks and strengthen evidence implicating drinking water as a common source of infection; however, capacity to conduct these investigations and report the results also differs What is already known on this topic?Despite advances in water management and sanitation, waterborne disease outbreaks continue to occur in the United States.CDC collects data on waterborne disease outbreaks submitted from all states and territories through the Waterborne Disease and Outbreak Surveillance System.
What is added by this report?During 2009-2010, a total of 33 drinking water-associated outbreaks were reported to CDC, resulting in 1,040 cases of illness, 85 hospitalizations, and nine deaths.Legionella accounted for 58% of outbreaks and 7% of illnesses, and Campylobacter accounted for 12% of outbreaks and 78% of illnesses.The most commonly identified outbreak deficiencies were Legionella in plumbing systems (57.6%), untreated ground water (24.2%), and distribution system deficiencies (12.1%).
What are the implications for public health practice?
Efforts to identify and correct the deficiencies implicated in drinking water-related outbreaks, particularly deficiencies in distribution systems and untreated ground water systems, could prevent many outbreaks and illnesses.Additional research is needed to understand the interventions that are most effective for controlling growth of Legionella and reducing outbreaks of legionellosis.
by state and locality, and might change over time.For these reasons, outbreak surveillance should not be used to estimate the total number of illnesses from waterborne disease because most cases of waterborne disease are believed to occur sporadically or as part of outbreaks that are never recognized.Second, changes in the surveillance system occurred during this cycle, namely implementation of electronic reporting of waterborne disease outbreaks and the assignment of multiple deficiency categories for Legionella outbreaks.These changes do not affect the internal validity of the data in this report but might limit the ability to interpret trends in the number of outbreaks and deficiencies across reporting periods.
As observed in recent years, the proportion of outbreaks in the federally regulated portions of public water systems has declined, although these still contribute the majority of outbreak-associated illnesses.Deficiencies at points not under the jurisdiction of water utilities (e.g., private wells and plumbing systems) continue to cause illness.In addition, challenges with aging water infrastructure are ongoing, and efforts to understand the number of illnesses associated with drinking water distribution system deficiencies are needed.Partnerships between state and local public health agencies, as well as cooperation and coordination among epidemiologists, laboratorians, and environmental health specialists within agencies, are needed to optimize investigation and reporting of waterborne disease outbreaks.Additional information about the waterborne disease outbreaks reported during 2009-2010 is available at http://www.cdc.gov/healthywater/surveillance/drinking-surveillance-reports.html.

Introduction
In the 1970s, a method for measuring the quality of medical care through identifying "untimely and unnecessary" deaths was proposed (1).This concept has since been expanded to include deaths attributed to lack of preventive health care (i.e., preventing cardiovascular events by addressing risk factors) or timely and effective medical care (i.e., treating patients who have cardiovascular conditions); these deaths are defined as avoidable (2).Although no standard method for measuring avoidable deaths exists, Canada (3), the United Kingdom (4), and the European Union (5) have introduced avoidable death measures for their surveillance systems.In several previous studies, the United States ranked higher in avoidable death rates compared with other industrialized countries (6).
Heart disease is the leading cause of death in the United States, and cardiovascular disease accounts for nearly 30% of all deaths annually (nearly 800,000 deaths) (7).Many heart disease and stroke deaths could be avoided through improvements in lifestyle behaviors, treatment of risk factors, and addressing the social determinants of health (i.e., economic and social conditions that influence the health of individuals and communities).Unhealthy lifestyle behaviors (e.g., tobacco use, inadequate physical activity, poor diet, and excessive alcohol use) coupled with uncontrolled hypertension, elevated cholesterol, and obesity account for 80% of ischemic heart disease mortality and approximately 50% of stroke mortality in high-income countries such as the United States (8).Hypertension is the single most important risk factor for stroke, and its control is essential to reducing death from stroke (8).Additional medical interventions, such as secondary prevention and evidence-based procedures to treat ischemic heart disease and stroke, have been shown to reduce deaths in the United States (9,10).
This report describes the epidemiology of avoidable deaths from heart disease, stroke, and hypertensive disease in the United On September 3, 2013, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr).
States, presents trends in avoidable death rates for these causes, and documents geographic disparities by state and county.

Methods
Mortality data from the National Vital Statistics System for the period 2001-2010 were analyzed.Bridged-race July 1 population estimates produced by the U.S. Census Bureau in collaboration with the National Center for Health Statistics were compiled using intercensal estimates for the period 2001-2009 and postcensal estimates for 2010.
In this report, avoidable deaths include all deaths among persons aged <75 years with an underlying cause of ischemic heart disease (International Classification of Diseases, 10th Revision [ICD-10] codes I20-I25), cerebrovascular disease (stroke) (I60-I69), hypertensive disease (I10-I15), or chronic rheumatic heart disease (I05-I09) (2).The analyses were limited to persons aged <75 years because the life expectancy of the total U.S. population in 2010 was 78.7, and 100% of these deaths in persons aged <75 years were considered to be preventable in accordance with previous analyses (3)(4)(5).Age-standardized death rates were calculated by sex, race/ethnicity,* and the decedent's state of residence at time of death, and trends were analyzed for the period 2001-2010 using joinpoint regression to calculate the average annual percentage change (AAPC).Rate comparisons were made using rate ratios (RRs).Countylevel rates for combined years 2008-2010 were calculated using a spatial empirical Bayesian smoothing technique to enhance the stability of the rates (11).

Results
In 2010, the total number of avoidable deaths from heart disease, stroke, and hypertensive disease was 200,070, and the death rate was 60.7 per 100,000 population (Table 1).Death rates in 2010 were highest in the oldest age group (65-74 years) (401.5 per 100,000) and lowest in the youngest age group (0-34 years) (1.9 per 100,000); however, 56% of the deaths (n = 112,329) occurred among those aged <65 years.Avoidable deaths were higher among males (83.7 per 100,000) than females (39.6) and blacks (107.3)compared with other races/ethnicities.Rates for blacks and American Indians/Alaska Natives were statistically significantly higher than those for whites (RR = 1.9 and 1.2, respectively), whereas rates for Hispanics and Asian/Pacific Islanders were significantly lower (RR = 0.8 and 0.6, respectively).
From 2001 to 2010, the avoidable death rate from heart disease, stroke, and hypertensive disease decreased 29%.The AAPC shows that rates decreased sharply for the 65-74 years age group (AAPC = -5.1),declined more gradually in the 55-64 years age group (AAPC = -3.3),declined minimally in the 35-54 years age group (AAPC = -0.8),and did not change in the youngest age group (Table 1).Declines occurred among both sexes and all race/ethnicity groups.Temporal trends for blacks and whites from 2001 to 2010 showed a decrease over time for all groups; however, black males consistently experienced the highest avoidable death rates throughout the period, and black females showed rates similar to white males (Figure 1).
By state, avoidable deaths from heart disease, stroke, and hypertensive disease in 2010 ranged from 36.3 to 99.6 per 100,000 population in Minnesota and the District of Columbia, respectively, a greater than two-fold difference (Table 2).All states experienced declines in rates for these avoidable causes during 2001-2010, ranging from an AAPC of -1.6 in Wyoming to an AAPC of -6.1 in New Hampshire.By county, the highest avoidable death rates in combined years 2008 to 2010 were concentrated primarily in the southern Appalachian region and much of Tennessee, Arkansas, Mississippi, Louisiana, and Oklahoma, whereas the lowest rates were located in the West, Midwest, and Northeast census regions † (Figure 2).Within states, substantial variation often occurred in the county rates, with some states experiencing a fourfold difference in death rates among counties (e.g., Colorado, Virginia, Kentucky, and Maryland).

Conclusions and Comment
Avoidable death rates from heart disease, stroke, and hypertensive disease in the United States vary by age, race/ethnicity, sex, place, and time.In 2010, an estimated 200,070 avoidable deaths from these causes occurred in the United States.Although the highest death rate occurred among those aged 65-74 years, the younger age groups (aged <65 years) still experienced a substantial number of avoidable deaths and a relatively slower rate of decline during 2001-2010.The avoidable death rate among blacks was nearly twice that of whites.Counties with the highest avoidable death rates were located primarily in the South census region.
The overall decrease in deaths from ischemic heart disease (the largest contributing cause of the avoidable deaths measured) can be attributed to both improvements in risk factors and changes in cardiac treatments (9).The variation * Persons of Hispanic ethnicity might be of any race or combination of races.
Persons identified as any of the other racial/ethnic categories were non-Hispanic.(12).Although avoidable death rates in those aged ≥35 years have declined over this interval, the increase in percentage without insurance among the younger age groups might have limited their access to preventive screenings and early treatment of high blood pressure and elevated cholesterol and, therefore, contributed to their slower decline in rates (13,14).Age-specific differences in risk factor management also might have contributed to the slower decline in the younger age group.Compared with persons aged ≥60 years, during 2009-2010, adults aged 18-39 years with high blood pressure experienced lower rates of treatment (43.5% versus 83.6%) and control (28.6% versus 47.0%) and saw no improvements in those rates from 2001 to 2010 (15).Furthermore, among persons aged 35-44 years, stroke hospitalizations increased during 2001-2006, whereas they remained constant for those aged 45-54 years and decreased among those aged 55-64 years (16).The finding of a slower decline in avoidable deaths in younger age groups in this report highlights the importance of improving prevention, diagnosis, and treatment efforts in younger adults.Blacks experienced a disproportionate number of avoidable deaths from heart disease, stroke, and hypertensive disease, with nearly twice the rate as whites.Risk for avoidable death is particularly high among black males; in 2010, their rate was approximately 80% higher than that of white males and black females.Compared with whites, blacks have higher prevalence of cardiovascular disease risk factors, including high blood pressure, diabetes, obesity, physical inactivity, low fruit and vegetable consumption, and poor low-density lipoprotein cholesterol control (13).In addition, previous studies suggest Abbreviations: CI = confidence interval; AI/AN = American Indian/Alaska Native.* Avoidable deaths from heart disease, stroke, and hypertensive disease are defined as all deaths occurring in persons aged <75 years with an underlying cause of ischemic heart disease, cerebrovascular disease, hypertensive disease, or chronic rheumatic heart disease.† Per 100,000 population.Rates are age-standardized to the U.S. standard 2000 population except for age-specific rates.§ Statistically different from zero at alpha = 0.05.¶ Results based on small numbers.** Numbers and rates for AI/ANs, Hispanics, and Asians/Pacific Islanders might be underreported because of coding issues on death certificates.that the U.S. black-white disparity in avoidable mortality reflects differences in education, income, living conditions, and access to health care (2).Interventions aimed at addressing these social determinants of health in combination with effective treatment and control of risk factors could help reduce black-white disparities in avoidable deaths (17).
State-level and county-level differences in avoidable death rates from heart disease, stroke, and hypertensive disease suggest the need for interventions that target areas with the highest rates and work with the resources, policies, and programs already existing in those areas.In 2010, the states with the highest avoidable death rates were located primarily in the South (e.g., District of Columbia, Mississippi, Oklahoma, Tennessee, and Louisiana).The states with the lowest rates were Minnesota, Utah, Colorado, Connecticut, and New Hampshire.During 2001-2010, all states experienced declines in avoidable death rates; however, some of the states that already had the lowest rates saw some of the steepest declines in absolute percentage change and AAPC (e.g., New Hampshire and Rhode Island), whereas some states with the highest rates had the slowest declines (e.g., Oklahoma and Arkansas).Moreover, variation in avoidable deaths exists within states by county (Figure 2).These geographic disparities support the need for local-level policy changes and system-level changes (e.g., promoting community design that increases access to sidewalks and bike lanes, improving the local food environment, enhancing worksite wellness programs, and improving insurance coverage) to improve access to quality health care and enhance or create the physical, social, and built environments needed to support healthy lifestyles (18).
The findings in this report are subject to at least four limitations.First, ICD-10 codes might misclassify cause of death, especially for stroke; however, more classification issues typically are experienced among the very old, a population not included in this study (19).Second, race and ethnicity might not be reported accurately on death certificates; this typically leads to underreporting of American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic race/ethnicity (20).Third, death rate data in this report are based on residency at time of death and not on the state in which a person spent the majority of his or her life.Finally, there is no universally agreed upon definition for avoidable heart disease and stroke deaths, which could limit ability to compare these results with other studies.The strength of the methodology used in this report (2) is that it focuses on both preventable and treatable conditions whereas other methodologies might focus on one or the other.Other definitions of avoidable deaths resulting from these causes could lead to differing estimates, but most likely similar trends and associations.
Strong collaboration between health care and public health is critical to reduce the burden of avoidable deaths from heart disease, stroke, and hypertensive disease.The Million Hearts initiative is a national effort working to improve access and quality of care to reduce the incidence of heart disease and stroke through community and clinical prevention strategies.These strategies include promoting the ABCS of heart health (aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation); use of health information technology (to help doctors track and treat patients with high blood pressure and elevated cholesterol); and team-based care (an evidence-based collaborative model that is more effective in controlling high blood pressure and cholesterol than a single health-care provider working alone), as well as community prevention strategies, including tobacco control and reducing sodium and eliminating trans fats from foods.In addition, state-level and local-level initiatives are working to enhance community and clinical collaborations.For example, the state of Massachusetts is developing an electronic referral system and data exchange to enhance communication between clinicians and community resources such as telephone quitlines for smokers, physical activity supports, and blood pressure self-management to prevent heart disease and stroke risk factors more effectively.The Sodium Reduction in Communities Program is a countylevel effort to help reduce sodium in schools, restaurants, and other venues while also educating the public on sodium reduction (21).Reducing sodium in foods can aid in control of high blood pressure.Finally, individuals can work toward reducing their own heart disease and stroke risk.The American Heart Association has defined seven simple steps to a healthier heart to help individuals increase healthy behaviors (22).Although this report defined avoidable deaths as those occurring in persons aged <75 years based on life expectancy in the United States, these public health, health-care, community, and patient strategies can help reduce deaths from heart disease and stroke in the United States across all age groups.to enhance the stability of rates in counties with small populations.† Avoidable deaths from heart disease, stroke, and hypertensive disease are defined as all deaths occurring in persons aged <75 years with an underlying cause of ischemic heart disease, cerebrovascular disease, hypertensive disease, or chronic rheumatic heart disease.§ Additional maps by race/ethnicity and sex are available on the Interactive Atlas for Heart Disease and Stroke at http://nccd.cdc.gov/dhdspatlas.

Investigation of a Cluster of Neural Tube Defects -Central Washington, 2010-2013
During August 2012, a health-care provider in central Washington alerted the Washington State Department of Health (DOH) about an excessive number of anencephaly births at a local hospital.After examining referral patterns for high-risk pregnancies in central Washington, DOH identified pregnancies affected by a severe neural tube defect (NTD) in a three-county area.Case findings included a review of area hospital discharge records for International Classification of Diseases, Ninth Revision codes 740, 741, 742, or 655.0; vital statistics reports; and perinatology office records.From these sources, 27 confirmed NTD-affected pregnancies occurring during January 2010-January 2013 were identified among women residing in the three-county area.Twenty-three pregnancies were affected by anencephaly, three with spina bifida, and one with encephalocele.The anencephaly rate was 8.4 per 10,000 live births (95% confidence interval [CI] = 4.5-12.0),compared with a national estimate of 2.1 per 10,000 live births (CI = 1.9-2.2) (1).In contrast, the rate of spina bifida was 1.3 per 10,000 live births (CI = 0.3-3.8),compared with 3.5 per 10,000 live births nationally (CI = 3.3-3.7)(1).
During February 2013, a case-control study was conducted by abstracting prenatal records from the 27 NTD-affected pregnancies and 108 randomly selected control subject pregnancies in women who had received care at the same 13 prenatal clinics.Control subjects were matched to case-patients by the month and year of last menstrual period.Eligibility criteria for control subjects included a pregnancy without an indication of a structural or genetic birth defect during routine prenatal care and prenatal residence in one of the three study counties.Information abstracted from medical records included sociodemographic characteristics, maternal and paternal occupations, maternal smoking and alcohol use, pregnancy health conditions (e.g., anemia, diabetes, or infectious diseases), parity, gravidity, prepregnancy height and weight, and medication use (including over-the-counter remedies, vitamins, and folic acid supplementation).Residential address during pregnancy was used to determine use of public versus private well-water supply.
No statistically significant differences were identified between cases and controls, and a clear cause of the elevated prevalence of anencephaly was not determined.DOH recommended reminding doctors about the importance of folic acid supplementation for women of childbearing age (2), and monitoring private well nitrate concentrations because of their potential association with birth defects and other adverse health outcomes (3).Active surveillance of new NTD cases began February 2013 and will continue through 2013.

Electronic Cigarette Use Among Middle and High School Students -United States, 2011-2012
Electronic cigarettes, or e-cigarettes, are battery-powered devices that provide doses of nicotine and other additives to the user in an aerosol.Depending on the brand, e-cigarette cartridges typically contain nicotine, a component to produce the aerosol (e.g., propylene glycol or glycerol), and flavorings (e.g., fruit, mint, or chocolate) (1).Potentially harmful constituents also have been documented in some e-cigarette cartridges, including irritants, genotoxins, and animal carcinogens (1).E-cigarettes that are not marketed for therapeutic purposes are currently unregulated by the Food and Drug Administration, and in most states there are no restrictions on the sale of e-cigarettes to minors.Use of e-cigarettes has increased among U.S. adult current and former smokers in recent years (2); however, the extent of use among youths is uncertain.
Data from the 2011 and 2012 National Youth Tobacco Survey (NYTS), a school-based, pencil-and-paper questionnaire given to U.S. middle school (grades 6-8) and high school (grades 9-12) students, were used to estimate the prevalence of ever and current (≥1 day in the past 30 days) use of e-cigarettes, ever and current (≥1 day in the past 30 days) use of conventional cigarettes, and use of both.NYTS consists of a cross-sectional, nationally representative sample of students in grades 6-12 from all 50 states and the District of Columbia (3).
Among middle school students, ever e-cigarette use increased from 1.4% to 2.7% during 2011-2012 (p<0.05)(Figure ); current e-cigarette use increased from 0.6% to 1.1% (p<0.05), and current use of both e-cigarettes and conventional cigarettes increased from 0.3% to 0.7% (p<0.05).In 2012, among middle school ever e-cigarette users, 20.3% reported never smoking conventional cigarettes; among middle school current e-cigarette users, 61.1% reported current conventional cigarette smoking.Among high school students, ever e-cigarette use increased from 4.7% to 10.0% during 2011-2012 (p<0.05)(Figure ); current e-cigarette use increased from 1.5% to 2.8% (p<0.05), and current use of both e-cigarettes and conventional cigarettes increased from 1.2% to 2.2% (p<0.05).In 2012, among high school ever e-cigarette users, 7.2% reported never smoking conventional cigarettes; among high school current e-cigarette users, 80.5% reported current conventional cigarette smoking.
E-cigarette experimentation and recent use doubled among U.S. middle and high school students during 2011-2012, resulting in an estimated 1.78 million students having ever used e-cigarettes as of 2012.Moreover, in 2012, an estimated 160,000 students who reported ever using e-cigarettes had never used conventional cigarettes.This is a serious concern because the overall impact of e-cigarette use on public health remains uncertain.In youths, concerns include the potential negative impact of nicotine on adolescent brain development (4), as well as the risk for nicotine addiction and initiation of the use of conventional cigarettes or other tobacco products.
CDC and the Food and Drug Administration will continue to explore ways to increase surveillance and research on e-cigarettes.Given the rapid increase in use and youths' susceptibility to social and environmental influences to use tobacco, developing strategies to prevent marketing, sales, and use of e-cigarettes among youths is critical.

3 )
Abbreviations: AGI = acute gastrointestinal illness; ARI = acute respiratory illness.*Public water systems include community and noncommunity water systems that have ≥15 service connections or serve an average of ≥26 residents for ≥60 days a year.A community water system serves year-round residents of a community, subdivision, or mobile home park.A noncommunity water system serves an institution, industry, camp, park, hotel, or business.† The category of illness reported by ≥50% of ill respondents.All legionellosis outbreaks were categorized as ARI.§ Outbreaks are assigned one or more deficiency classifications.Deficiency names have been shortened to fit.A full description of CDC deficiency classification is available at http://www.cdc.gov/healthywater/surveillance/deficiency-classification.html.¶ Two outbreaks had multiple etiologic agent types.In one outbreak, the etiologies were Camplyobacter sp.(i.e., bacterium) and Giardia intestinalis (i.e., parasite).In a second outbreak, the etiologies were Campylobacter jejuni (i.e., bacterium) and Cryptosporidium sp.(i.e., parasite).** Etiology unidentified: contamination of water with sodium hydroxide suspected based upon incubation period, symptoms, outbreak investigation, and laboratory findings.† † Ten outbreaks (763 cases) were in community water systems that used a ground water source exclusively.Of these, three outbreaks (111 cases) were in systems that were documented as not treating the water with a disinfectant, five outbreaks (645 cases) were in systems that added chlorine as a disinfectant, and two outbreaks (seven cases) had no information on disinfection documented.§ § Includes outbreaks with mixed water sources (i.e., ground water and surface water).Three legionellosis outbreaks were associated with mixed source community water systems.One giardiasis outbreak was associated with a mixed source community water system.¶ ¶ Symptoms for one outbreak caused by suspected chemical ingestion were categorized as AGI and other.The other symptoms reported were chemical esophagitis and burns in mouth.*** Hepatitis symptoms are categorized separately.One outbreak of viral hepatitis was caused by hepatitis A.† † † Deficiency 5A.Drinking water; contamination of water at points not under the jurisdiction of a water utility or at the point of use: Legionella spp. in water system, drinking water.§ § § Multiple deficiencies were assigned to three Legionella outbreaks.In two outbreaks, which contributed five cases, there was a deficiency in building/home-specific water treatment.In one outbreak, which contributed three cases, there was a treatment deficiency outside of the building/home as well as a deficiency in the plumbing system.¶ ¶ ¶ Deficiency 4. Drinking water; contamination of water at/in the water source, treatment facility, or distribution system: distribution system deficiency, including storage (e.g., cross-connection, backflow, and contamination of water mains during construction or repair).The four outbreaks involving distribution system deficiency included three outbreaks in systems using only ground water sources and one outbreak in a system using both ground and surface water.Two of the three ground water systems disinfected with chlorine, one ground water system and the system using ground and surface water did not disinfect.**** Deficiency 2. Drinking water; contamination of water at/in the water source, treatment facility, or distribution system: untreated ground water.†† † † Outbreak involved both Deficiency 2 and Deficiency 4. Outbreak occurred in a nontransient, noncommunity water system using a ground water source that was not treated with a disinfectant.§ § § § Deficiency 11C.Drinking water; contamination of water at points not under the jurisdiction of a water utility or at the point of use: contamination at point of use, commercially bottled water.

FIGURE 1 .
FIGURE 1. Age-adjusted rates* of avoidable death from heart disease, stroke, and hypertensive disease † among non-Hispanic blacks and non-Hispanic whites, by sex -United States, 2001-2010

FIGURE.
FIGURE.Ever electronic cigarette use* among middle and high school students, by year -National Youth Tobacco Survey, United States, 2011-2012

TABLE 1 . Characteristics of waterborne disease outbreaks associated with drinking water (N = 33) and other nonrecreational water* (N = 12), by state/jurisdiction -Waterborne Disease and Outbreak Surveillance System, United States, 2009-2010 Exposure category and state/ jurisdiction Month Year Etiology Predominant illness † No. of cases No. of hospital- izations § No. of deaths ¶ Water system** Water source Setting Drinking water
See table footnotes on page 716.

TABLE 1 . (Continued) Characteristics of waterborne disease outbreaks associated with drinking water (N = 33) and other nonrecreational water* (N = 12), by state/jurisdiction -Waterborne Disease and Outbreak Surveillance System, United States, 2009-2010
).The outbreaks * Legionnaires' disease outbreaks were first reported to the Waterborne Disease and Outbreak Surveillance System in 2001; Legionnaires' disease outbreaks before 2001 were added retrospectively during the 2007-2008 reporting period.† Includes all bacteria except Legionella.

TABLE 2 . Etiology, water system,* water source, predominant illness, † and deficiencies § associated with drinking water outbreaks (N = 33) and outbreak-related cases (N = 1,040), ranked in order of frequency -Waterborne Disease and Outbreak Surveillance System, United States, 2009-2010
age-specific rates of decline for avoidable deaths from heart disease, stroke, and hypertensive disease, with slower declines in the younger age group, could have resulted from multiple factors.Differential temporal trends in the percentage of adults without health insurance by age group are one possibility.Whereas the percentage of adults aged 18-64 years with no health insurance increased from 17% in 2001 to 22% in 2010, it remained at ≤2% among adults aged ≥65 years (because of Medicare coverage in this population) Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, Oklahoma, North Carolina, South Carolina, Tennessee, Texas, Virginia, and West Virginia.in